- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.13 / $2,673.13 / $15,797.84
| Facility | | $2,673.13 | $2,673.13 | $15,797.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.34 / $79.34 / $117.90
| Professional | | $79.34 | $79.34 | $117.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,675.00 / $2,675.00 / $2,675.00
| Professional | | $2,675.00 | $2,675.00 | $2,675.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.00 / $507.00 / $641.21
| Facility | | $507.00 | $507.00 | $641.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.00 / $37.00 / $41.00
| Facility | | $36.00 | $37.00 | $41.00 |